LFT Derangement

History

• Recent Antibiotics, Herbal Medications (e.g. mistletoe), hepatotoxic substances (mushroom toxins, vinyl chloride)

• Alcohol Intake: Quantify standard drinks per week

• Hepatitis B Risk Factors: IV drug use, overseas travel, vaccination status

• Obesity: Non-alcoholic fatty liver disease (NAFLD/NASH)

• Stool/Urine Colour Changes (pale stools, dark urine → cholestatic picture)

• Family History: Autoimmune liver disease, haemochromatosis (arthralgia, skin pigmentation)

Associated Conditions

• Inflammatory Bowel Disease: PSC (primary sclerosing cholangitis)

• Right Heart Failure: Congestive hepatopathy (raised JVP, oedema)

• Haemochromatosis: Arthropathy, diabetes, cardiomyopathy, skin pigmentation

• Alpha-1 Antitrypsin Deficiency: Emphysema < age 40, liver dysfunction

• Coeliac Disease, Hypothyroidism: Can contribute to mild LFT elevation

Exam Findings (RACGP Exam Grid)

• Spider Naevi, Palmar Erythema, Jaundice → Chronic liver disease

• Ascites, Peripheral Oedema → Decompensated cirrhosis

• Asterixis (flapping tremor) → Hepatic encephalopathy

• Hepatosplenomegaly → Chronic liver disease, haemolysis

• Finger Clubbing → Chronic hypoxia or GI/liver disease

• Caput Medusae → Portal hypertension

• Virchow’s Node (left supraclavicular) → Malignancy

• Gynaecomastia, Testicular Atrophy → Chronic liver disease (male hypogonadism)

• Bruising, Leukonychia, stigmata of IV drug use if suspect viral hepatitis

Investigations

Bloods

• Hepatitis B/C Serologies, Iron Studies (haemochromatosis)

• Autoimmune Markers: ASMA (autoimmune hepatitis), AMA (PBC), ANA (SLE overlap)

• TFTs, Coeliac Serology if indicated

• α1-Antitrypsin level → deficiency?

• Serum Caeruloplasmin for Wilson’s disease (especially in younger patients with neurological/liver issues)

Imaging

• Ultrasound Abdomen: Assess for biliary duct dilatation → possible obstructive or cholestatic pattern

• MRCP/ERCP: If bile ducts are dilated or ALP significantly elevated, and initial ultrasound is inconclusive

Other Tests

• Albumin: Often low in chronic liver disease, can be normal in acute disease

• Prothrombin Time: Prolonged in significant hepatic synthetic dysfunction

When to Refer

• Unexplained, persistent LFT abnormalities, e.g.

  • AST/ALT > 2× normal

  • ALP > 1.5× normal

  • No improvement after 6 months of monitoring

• High Ferritin > 1000 µg/L with elevated liver enzymes → assess for haemochromatosis

• Suspicion of advanced or complex liver disease (signs of portal hypertension, coagulopathy, significant cholestasis)

• Progressive jaundice, potential malignancy or complicated biliary obstruction → urgent referral